Percutaneous transhepatic cholecystostomy for acute complicated calculous cholecystitis in elderly patients.

OBJECTIVE: To assess the immediate and long-term outcomes of elderly patients with acute complicated cholecystitis treated by percutaneous cholecystostomy. To assess the results of bile cultures obtained in this group of patients. DESIGN: Case series. SETTING: Tertiary care center. PATIENTS: Thirty-two patients, with a mean (+/- S.D.) age of 78 +/- 8 years (range, 58-92 years), and who presented with acute cholecystitis complicated by empyema formation. Sixty-six percent had associated disorders, which rendered them at high risk for surgical intervention. INTERVENTION: Percutaneous transhepatic catheter drainage of the gallbladder, with a mean drainage time of 20 days (range 0-84 days). In addition, endoscopic sphincterotomy with removal of common bile duct stones was performed in six patients and percutaneous aspiration of an associated liver abscess in four cases. RESULTS: Percutaneous cholecystostomy was followed by rapid regression of clinical symptoms and of radiologic abnormalities in all patients. Sixteen cases (50%) underwent elective cholecystectomy 1-12 weeks after cholecystostomy. One of them died of aspiration pneumonia, whereas 15 had no post-operative problems and were discharged 9 days (mean) after surgery. Forty-four percent (14/32) were considered inoperable: they remained completely free of biliary symptoms and died of unrelated illness (22%) after a mean follow-up of 6 months (range, 1-22 months) or are still alive (22%) with a mean follow-up of 15 months (range, 5-36 months). Bile cultures were positive in 75% of the patients. Escherichia coli, other aerobic Gram-negative micro-organisms, and anaerobic bacterial species accounted for 35% (16/46), 28% (13/46), and 20% (9/46) of the isolated bacteria, respectively. All aerobic Gram-negative species tested in vitro were susceptible to gentamicin and to temocillin. CONCLUSIONS: Percutaneous transhepatic cholecystostomy is a safe and effective procedure in the treatment of elderly high-risk patients with acute cholecystitis complicated by empyema formation. It can be followed by elective cholecystectomy, if possible, or by expectant conservative management in patients who are inoperable because of systemic disease.

Chronic renal failure due to renal hemosiderosis in a patient with paroxysmal nocturnal hemoglobinuria.

We report on a 44-year-old man with paroxysmal nocturnal hemoglobinuria, who developed renal hemosiderosis, interstitial nephritis, and chronic renal failure. Classically, it is assumed that the renal function is only uncommonly affected by this pathology. In most instances the renal hemosiderosis is an incidental finding at postmortem examination. In our case the presence of iron in the kidney, as confirmed by CT scan, magnetic resonance imaging and renal biopsy, occurred concomitantly with the development of renal insufficiency. A direct nephrotoxic effect of iron by the induction of highly reactive hydroxyl radicals is suggested.

Enhancement of the pancreas after single bolus injection combined with spiral scanning. A comparative study with conventional incremental scanning after biphasic contrast injection.

The combination of a rapid single bolus injection (72 ml of a 60% concentrated iodinated contrast medium) with spiral scanning versus dynamic sequential scanning with a conventional biphasic bolus injection (150 ml of 60% concentrated iodinated contrast medium) is compared. 60 patients with normal pancreatic morphology were included in this study. 30 patients were examined with dynamic sequential scanning (cycle times of 5 seconds) during a biphasic bolus injection, 30 patients were examined with spiral scanning (cycle times of 1 second) after a single uniphasic bolus injection. For both scanning techniques, mean attenuation values of the pancreas were measured before and at different time intervals after contrast injection. The difference in attenuation values of the pancreas before and after contrast injection reflects the level of contrast enhancement in both methods. The level of contrast enhancement of the pancreas after bolus injection was not statistically significantly different in spiral scanning versus in dynamic sequential scanning. In comparison with conventional scanning, spiral scanning allows to reduce the injected dose of contrast by 50% without compromising the contrast resolution.

Comparison of ultrasound and E.R.C.P. in the detection of the cause of obstructive biliary disease.

The value of ultrasound (US) in determining the cause and site of biliary obstruction was critically evaluated and compared to endoscopic retrograde cholangiography (ERCP), in a prospective study performed on 120 consecutive patients. The final diagnosis was based on surgery, endoscopic retrograde cholangiography or a combination of other examinations. Ultrasound successfully differentiated obstructive from non obstructive jaundice in 96% of the patients, comparing well with the results ERCP. US correctly defined the cause of obstruction in 71% of the patients with ductal stones, in 90% of the patients with tumoural bile duct obstruction, but only in 59% of the patients with chronic pancreatitis.

Transient focal fatty liver infiltration mimicking liver metastasis.

The case of a 76-year-old woman presenting with focal liver lesions suggesting liver metastasis on CT is reported. A control CT performed one week later showed a normal liver. Biopsy revealed the diagnosis of focal liver steatosis. The final diagnosis of transient focal steatosis is proposed.

Congenital intrahepatic porto-systemic shunt.

An asymptomatic case of intrahepatic shunt between a portal and hepatic vein is presented. Ultrasound examination combined with Doppler sonography showed a communication between a dilated portal vein and a hepatic vein. Computed tomography and angiography confirmed the findings. Porto-hepatic venous shunting is very rare and has previously been reported in association with cirrhosis. The vascular malformation we present is believed to be a congenital anomaly, as no signs of cirrhosis or trauma were found.

A semi-automated program for volume measurement in focal hepatic lesions: a first clinical experience.

The value of a semi-automated program for volumetric measurements was tested in 53 patients with liver lesions. Three different radiologists performed 10 measurements on a liver lesion in each patient. The variances of the measurements were calculated. There was no difference in intra- and interoperator variance of the measurements. If the diameter of the liver lesion exceeded the slice thickness, the different measurements became more reliable and more reproducible. The semi automation of the volume measurements makes its use in daily clinical practice possible. Volume measurement can be interesting in the follow-up and evaluation of the treatment on tumor reduction. However further and more thorough investigation is needed to test the clinical usefulness of the program.

Spina ventosa: the forgotten diagnosis. Report of one case, review of literature.

A child 3 years of age is admitted to our hospital for surgical treatment of a lesion diagnosed elsewhere as an enchodroma. Our diagnostic studies revealed a case of spina ventosa. After five months of tuberculostatic treatment there is a clinical and radiological clear regression of the lesion. In order to prevent fistulisation and further unfavourable expansion of the lesion, the early diagnosis of this rare entity is mandatory.

Chronic focal fibrosing pancreatitis: detection by MRI.

The study of a 70-year-old woman with fibrosing pancreatitis, an uncommon variety of chronic pancreatitis, presenting as a discrete solid mass in the head of the pancreas, is reported. CT and US were non-diagnostic while ERCP and MR detected a focal anomaly. This case report stresses the sensitivity of MR in some pancreatic pathologies.

Contribution of MRI and color Doppler sonography in breast cancer diagnosis.

Thirty female patients were examined with both MRI (30) and color Doppler sonography (24). MRI after injection of Gadolinium DTPA in combination with fast 3D FLASH sequences makes it possible to plot out signal-intensity changes over a certain period of time. Flow within a malignant breast lesion can be depicted with color Doppler sonography. The signal intensity increase pattern over a period of time, and the detection of color Doppler flow are of major importance for the differential diagnosis in breast cancer.

MR imaging of a diverticulum in a female urethra.

The case of a 44-year-old woman with urethral diverticulum is described. The lesion was initially detected by ultrasonography. MRI proved to be very sensitive in localising and delineating the urethral diverticulum and could differentiate it from lesions arising from the vagina or bladder.

Contrast-enhanced MRI of the breast: technique and indications.

Magnetic Resonance Imaging of the breast is a recent promising technique. Today this technique is still dedicated to problematic cases or has very specific indications and cannot be regarded as a screening technique. However, MRI of the breast has already proved to be very reliable in the differentiation between tumor recurrence and scar formation, in the preoperative evaluation of tumor extension, the detection of a tumor recurrence adjacent to a breast prosthesis, the response of tumors to radiotherapy and/or chemotherapy, and can also be helpful in the differentiation between benign and malignant breast lesions. For these reasons, MR of the breast has already achieved a place in the diagnosis of breast tumors.

Sonographic diagnosis of ischemic colitis.

An abdominal ultrasound examination performed on two patients with abdominal pain showed segmental wall thickening of the colon that proved to be due to ischemic colitis. In one case, the typical "target lesion" was recognized. These findings could be confirmed with computed tomography, whereas a single contrast enema was unable to demonstrate the ischemic disease. In the second case, a typical five-layered structure of the bowel wall could be demonstrated. It is concluded that US can be useful in the early diagnosis of colonic ischemia.

Detection of small mucosal and submucosal polyps with helical CT scanning in a patient with intestinal neurofibromatosis.

The detection of small (diameter 5-12 mm) mucosal jejunal polyps and small (diameter 14-26 mm) submucosal rectal polyps with helical C.T.-scanning in a patient with neurofibromatosis is described. Because a volume is scanned with helical CT, overlapping image reconstructions can be made allowing to produce a contiguous image set for cine mode display. The combination of 'volume scanning' with cine mode display helps in the dynamic visualization of the course of the intestinal loops. This might result in a better depiction of small lesions within the bowels and in a better differentiation between mucosal folds and the lesions.

Duplex Doppler evaluation of renal allograft dysfunction: Doppler signal quantitation and pathologic correlation.

The value of quantitative duplex Doppler sonography in discriminating the different possible causes of renal transplant dysfunction was prospectively studied in 60 patients during 65 episodes of renal function impairment. Final diagnosis at histology was acute rejection (n: 30), acute tubular necrosis (n: 4), cyclosporin nephrotoxicity (n: 16) and chronic rejection (n: 15). Duplex sonography was done the day a percutaneous biopsy was taken and before any therapy was started. Arterial Doppler signals obtained from the segmental, interlobar and arcuate arteries were both morphologically and quantitatively analysed. For quantitative analysis we used the resistive index as proposed by Pourcelot on the one hand, and introduced a variant resistive index on the other hand. Morphological analysis yielded no discriminative value. Comparing both quantitative methods--the resistive index of Pourcelot and the variant resistive index--clearly higher specificities--71% using the variant resistive index, 28% using the resistive index of Pourcelot--for excluding acute rejection from the other possible causes of renal function impairment could be achieved. A nephrectomy was done on 7 patients with severe transplant dysfunction. Microangiographies performed on these nephrectomy specimens were correlated with previous Doppler studies and with histology.

[Ambulatory myelography using iohexol (Omnipaque): methods and results]. / Ambulante myelografie met iohexol (Omnipaque): methode en resultaten.

Outpatient myelography with iohexol (Omnipaque) was performed in 150 patients. Side effects were noted in 28 patients (19%), with only 3 (2%) major complaints. It concerned 2 patients with severe and prolonged headache and one patient with seizures. Side effects were not more frequent in outpatient myelography than in reported series of hospitalized patients. The frequency of side effects was significantly lower with the use of iohexol than in comparable studies with metrizamide. Headache was the most frequent side effect, followed by an increase or exacerbation of ischiatiform pain, nausea and vomiting. Side effects were slightly more frequent in cervical myelography than in lumbar myelography and were not related to underlying pathology. It is concluded that outpatient myelography is feasable for as far as iohexol is used and patient surveillance is carefully organized.

[Meigs' syndrome]. / Meigs syndroom.

Ascites and pleural effusion associated with "fibroma-like ovarian" benign tumor is described as Meigs syndrome. Tumor extirpation resulted in ascites and pleural effusion resorption. This rather unusual syndrome, should not be overlooked.

Imaging of polypoid endoluminal growing bile duct tumors.

We reviewed the radiological documents and protocols of 196 cases of bile duct tumors examined over a period of 12 years: 20 of them (10.2%) presented with a polypoid endoluminal growth. The aim of this study was to provide a better knowledge about the radiological features of this less frequent kind of tumor. In these 20 cases, the correct diagnosis of bile duct lesion was provided in 100% by E.R.C.P., P.T.C., U.S. as well as C.T., and in 42% by arteriography. The correct diagnosis of tumor was made by E.R.C.P. in 86%, by P.T.C. in 88%, by U.S. in 61%, by C.T. in 63%, and by arteriography in 25%. A correct diagnosis of tumor could be reached in all cases by combination of several examination techniques. The anatomopathological diagnosis was: bile duct adenocarcinoma (7 cases), adenocarcinoma of the ampulla of Vater (4), villous adenoma of Vater's ampulla (2), cystadenoma (1), cystadenocarcinoma (1), hepatocellular carcinoma (1), apudoma (1), and metastases (3).

An elderly woman with obstructed obturator hernia: a less common variety of external abdominal hernia.

Obturator hernia is a type of external abdominal hernia. Site of hemiation is the obturator canal, which is the superolateral aspect of the obturator foramen. The herniation sac exits the pelvis near the obturator nerve and vessels. Herniated loops of small bowel extend between the pectineus and obturator muscles. In this report, we present a case of obstructed obturator hernia.

Evaluation of peri-tumoral vessels surrounding colorectal liver metastases after intravenous injection of extruded magnetoliposomes in rats: correlation with 3T MRI and histopathology.

BACKGROUND: Magnetoliposomes have pronounced signal-enhancing effect on T1-weighted (T1w) images of the liver using qualitative analysis which may be benefical for demonstrating peritumoral vasculature. PURPOSE: To correlate peri-tumoral vasculature (ring-enhancement) surrounding colorectal liver metastases after injection of magnetoliposomes using T1-weighted (T1w) imaging with histopathology in a rat model. MATERIAL AND METHODS: All experiments were approved by the responsible Animal Care Committee. Three rats injected with CC531 coloncarcinoma cells in the portal vein were imaged at 3T using a small diameter four channel coil. The presence of liver metastases, signal intensity changes within intrahepatic vessels, peri-tumoral vasculature (ring-enhancement) surrounding liver metastases on T1w imaging and histopathology, and the histopathological distribution of iron particles were evaluated. SS SE-EPI and T1w GE sequences were used. Images were evaluated qualitatively and MRI findings were correlated with histopathology. RESULTS: Fifteen liver metastases were present which were all detected at MRI (mean diameter 2.4 mm (SD 0.8 mm, range 1.5-4.7 mm)). Ring-enhancement surrounding liver metastases at contrast-enhanced T1w GE sequences was present in all liver metastases. Correlation with histopathology showed the corresponding presence of dilated sinusoids filled with iron particles surrounding the liver metastases. CONCLUSION: Blood-pooling of iron oxide particles within magnetoliposomes was demonstrated with increased and hyperintensity of vessels after injection of magnetoliposomes. Qualitatively, ring-enhancement surrounding the liver metastases was seen on T1w imaging and corresponded histopathologically with the presence of iron particles (magnetoliposomes) within the dilated sinusoids surrounding the liver metastases.